Ciclosporin/prednisone/mycophenolate-mofetil

Abstract

Septic arthritis due to Streptococcus sp. infection: case report A 58-year-old woman developed septic arthritis due to Streptococcus sp. infection during immunosuppressive treatment with ciclosporin, prednisone and mycophenolate-mofetil [routes and durations of treatments to reaction onset not stated]. The woman, who had end-stage renal disease caused by chronic glomerulonephritis after allogenic kidney transplant 25 years previously, admitted to hospital with fever, accompanied by pain localised in the sacroiliac region radiating to the left lower limb. She had been receiving chronic immunosuppressive therapy with ciclosporin [cyclosporine A] 75mg twice daily, mycophenolate mofetil 500mg twice daily and prednisone 5mg once daily. On presentation, the blood level of ciclosporin was found to be in the range appropriate to the period after kidney transplant. Empiric antibiotic therapy with clindamycin was initiated. On the tenth day of hospitalisation, oedema with a tenderness of the left knee appeared. Due to exudates and excessive warmth of the left knee, arthrocentesis was performed. The synovial fluid tested positive for Streptococcus sp. (saprophytic flora). She was considered to have developed septic arthritis due to Streptococcus sp. infection. The immunosuppressive therapy was considered as risk factor for Streptococcus sp. infection. Therefore, the woman’s treatment was stared with vancomycin. Later, doppler ultrasound showed an active deep vein thrombosis. Therefore, she received unspecified low molecular weight heparin. A control ultrasound examination showed no features of thrombosis or valvular insufficiency. Despite antibiotic treatment, inflammation parameters were elevated. Therefore, further investigation was performed for detection of atypical infection, which was negative. Subsequently, she was transferred to the Department of Rheumatology. At that time, she reported left knee pain sustained for more than a month and lumbar spine pain. Meanwhile, the antibiotic therapy was completed, whilst the anti-coagulant therapy was continued. After the negative result of control culture of the synovial fluid, she received intrarticular injection of bethametasone and lidocaine in the sacroiliac joints. After thorough investigation, she was diagnosed with ankylosing spondylitis. She started treatment with sulfasalazine and unspecified NSAIDs, which showed good result. Radiosynovectomy in the left knee joint was performed, and after 2 weeks she was discharged home in a good general condition. She continued immunosuppressive therapy at the same dose. However, the dose of prednisone was increased up to 20mg once daily at the time of ankylosing spondylitis, with subsequent reduction to 5mg once daily. After 6 years of follow up, her graft function was stable, and she had no complaints associated with the left knee.